Ct Youth Camp Health Exam Form
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1
2YOUTH CAMP HEALTH EXAM/RECORD
Approved by CT-
FOR CAMPERS AND STAFF
American Academy
State of Connecticut
Department of Public Health
State of Connecticut
of Pediatrics
Division Community Based Regulation
Physical Exams Are Valid For 3 YearsDepartment of Public Health
1-800-282-6063; (860) 509-8045
From Date of Last Examination
Approved by CT-American Academy of Pediatrics
Camper
Staff
Name
__________ Date of Birth
Phone
Guardian
Address
Emergency Contact
Telephone
Date of Arrival at Camp:____________________________________________ Departure Date:_____________________________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
TO BE COMPLETED BY THE SPECIFIED MEDICAL PRACTITIONER:
Date of Exam_________________
________ May participate in all camp activities
________ May participate except for: ______________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Medical information pertinent to routine care and emergencies:
! YES
! NO
Is this individual taking prescription medication?
If yes, indicate prescription:__________________________________________________________________________________
! YES
! NO
Does the individual have allergies?
Explain:
! YES
! NO
Is the individual on a special diet?
Explain:
This camper/staff is up-to-date on all the following routine childhood immunizations currently recommended by the American
Academy of Pediatrics and National Advisory Committee on Immunization Practices:
Yes
No
Yes
No
Measles
Hepatitis B
Mumps
Diphtheria
Rubella
Pertussis
Chickenpox
Polio
Tetanus
Comments: __________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Print name of medical care provider: _______________________________________________
Medical care provider’s address: __________________________________________________
Medical care provider’s: City/Town______________________________ST___________Zip Code__________
Signature of Physician, APRN or PA
Date Form Signed
______________________________________________________________
TelephoneNumber
S:Division\Camps\Camps2001\AppPkg2001\Nurse, First Aider forms\Camper, Staff Health Record.doc new 2001
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